First name:
Last name:
Title
Supervisor name:
Name of organization
Mailing address:
City:
State:
Zip code:
Business phone:
Fax:
Cell phone:
Email address:
Website:
Brief description of your organization:
Personal interest/goal for joining:
Special skills or talents:
Current/Past community involvement in children's health issues:
Agreement: By checking this box I affirm that I have read the HCHC membership commitment letter and agree to abide by the bylaws.